PEDIATRICS Vol. 115 No. 2 February 2005, pp. 514 (doi:10.1542/peds.2004-2284)
There Might Be Gold at the End of the Rainbow
Lance Chilton, MDLovelace Medical Center
Albuquerque, NM 87108
To the Editor.—
In the process of evaluating policy statements in process for the American Academy of Pediatrics, reviewers of "intents for statement" are asked: "Does the intent appropriately reflect a consideration of cost-benefit and risk-benefit analyses?" I believe this is an appropriate question to ask and wonder how the question might have been avoided in the case of an otherwise very useful recent policy statement, "Prenatal Screening and Diagnosis for Pediatricians."1
The authors from the American Academy of Pediatrics Committee on Genetics state that "[p]renatal diagnosis is indicated whenever there is a familial, maternal, or fetal condition that confers an increased risk of a malformation, chromosome abnormality, or genetic disorder"1(p889) (emphasis added). I submit that there are instances in which obtaining such information is not useful, carries risks of its own, or may not be worth the often substantial cost of the procedures. For example, if a couple is philosophically opposed to termination of pregnancy, it may not be useful to know if one is carrying a child with sickle cell anemia or Down syndrome. There are financial and emotional costs for false-positive tests. The risk of chorionic villus sampling or amniocentesis may not justify its use when prenatal therapy or emergent therapy for a suspected disorder is not available on delivery.
Ginsburg notes that "new medical technology has been the dominant driver of increases in health care costs and insurance premiums."2(p1591) We need, Ginsburg concludes, "a candid national discussion about health care costs. If not, we will find ourselves on a downward spiral, as more and more resources are used to pay for the health care of fewer and fewer Americans."2(p1593)
Many patients in the emergency department of the hospital in which I work have blood drawn shortly after entry for a "rainbow," so named because it requires tubes with stoppers of a Joseph's coat-like array of colors. All too often those tubes are turned into blood tests; some are needed, some are not. Not infrequently, follow-up testing is needed to chase after abnormal tests, some of which are true-positives and some are not.
The American Academy of Access promotes 3 principles of its advocacy for children and pediatricians: access, reimbursement, and quality. I would add a fourth, responsibility. We must be responsible not only for individual patients but also for allowing health care to be affordable for all the children of the United States, if not of the world.
Genetic and all other tests should be done judiciously and with a concern about costs and benefits, not just because they can be done. As with those tubes of blood, there is not always gold at the end of the rainbow.
REFERENCES
- Cunniff C; American Academy of Pediatrics, Committee on Genetics. Prenatal screening and diagnosis for pediatricians.
Pediatrics. 2004;114
:889
–894
[Abstract/Free Full Text] - Ginsburg PB. Controlling health care costs.
N Engl J Med. 2004;351
:1591
–1593
[Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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- There Might Be Gold at the End of the Rainbow: In Reply
- Christopher Cunniff
Pediatrics 2005 115: 514-515.[Extract] [Full Text]
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